Abstract

A cesium-137 radioactive source was left in an abandoned clinic in the
city of Goiânia, capitol of the Brazilian state of Goiás.
Scavengers took the massive device, gouged out the iridium window, which
allowed high gamma radiation and a beautiful blue light to escape, and sold it
to a junk-yard owner. The blue glow of the small cylinder of cesium chloride that was inside the device made it appear very valuable, so it was broken into
pieces and used for decorative or magical purposes, including rubbing on the
skin.8 A six-year-old girl ingested some of it. At least 244 persons had
measurable contamination of cesium chloride on or in their bodies, with twenty
of them being seriously radiated. Ten of the twenty had extensive
decontamination and radiation-damage treatment. To date four of these have
died. The root cause of this incident appears to be lack of adequate accounting
and inspection procedures for radioactive sources in Brazil; the organization
charged with designing and executing such procedures is the same organization,
which has close ties to the military, that promotes the nuclear industry in
Brazil. Also, deficiencies were evident in the handling of the incident.

Herein we describe the details of the incident, the reporting of the
press, the fear of the populace, the reactions of the various government
agencies, and the deficiencies in maintenance and inspection of nuclear
materials and x-ray facilities in Brazil. We also discuss in general terms the
nuclear industry in Brazil.

Introduction

Goiânia, the second of Brazil's planned state capitols (for the
state of Goiás), was founded in 1933 in a frontier of Brazil, but now is
on the edge of Brazil's coastal population belt 210 kilometers west-southwest
of Brazil's capitol Brasília. At first glance, with its more than one
million people, scores of tall buildings, many cars and trucks, good airport
with many daily flights, federal university, and large professional cadre and
business elite, Goiânia appears to be a modern city. But, as for other
Brazilian cities, there is a wide educational and financial gap between the
upper and lower classes and a small middle class. Because of this gap, as in
many developing counties, there are juxtaposed modern high technology devices
and procedures with marginal ways of living. The "Goiânia Radiation
Incident" (herein called GRI) is a tragic example of the clash between overlaid
marginal and technological ways of living.

When radiation therapy devices for cancer treatment became widely
available in the decades following World War II, Brazil's well-educated medical
elite were not far behind in obtaining them. Goiânia now has two modern
cobalt-60 sources, an electron accelerator and possibly other devices. GRI
leads one to believe that some of these sources are located in obscure clinics
in Brazil and some are operated by ill-trained persons, with little accounting
of their location and use and negligible inspection of them by a regulatory
agency. The federal agency (Comissão Nacional do Energia Nuclear - CNEN,
which will be discussed later) with regulatory jurisdiction over radiation
therapy devices is a somewhat secret organization, with close ties to the
military, that also vigorously promotes nuclear applications, both civilian and
military, in Brazil.

The Goiânia Radiation Incident (GRI), which involved an outdated
cesium source, will probably result in the deaths of about ten persons within a
few years and may considerably shorten the lives of another hundred or more. At
writing date four persons have died.

We think the word "incident" better describes this event than the word
"accident", because it was caused by the clinic owner deliberately leaving the
source in an abandoned clinic and by the government not adequately regulating
radiation sources, rather than by a failure of equipment or in the operation of
equipment. The press compared GRI to the Chernobyl reactor accident in the
Soviet Union, stating that GRI was second only to Chernobyl in severity.
Despite some similarities in contamination and radiation released and the
effects on humans, we see no similarities in causes between the Chernobyl
accident and GRI.

Herein we describe the radiation therapy and diagnostic devices used in
Brazil, including x-ray machines, and discuss CNEN, the government agency that
regulates these devices. We detail a probable chronology of the relevant events
involving the cesium source responsible for GRI. And we discuss the roles of
the press, government officials, and medical and physics professionals in
coping with the technical and sociological aspects of GRI. Finally, we discuss
some reforms for better federal controls in Brazil of nuclear radiation
sources, which were proposed by scientific organizations in Brazil before
GRI.

Radiation Therapy Devices for
Cancer Treatment in Brazil

The first cesium-137 radiation therapy device was imported into Brazil
from the United States in the 1950's. This early type of device was involved in
GRI. In the 1960's more modern cobalt-60 devices were imported. Reports
indicate that no government organization knows exactly how many cesium-137 and
cobalt-60 sources there are in Brazil or how many cesium sources are still
being used or what has happened to some of the cesium sources that were
superseded by the cobalt sources. Of course, the entire world knows what
happened to one of the cast-off cesium-137 sources; it was left in an abandoned
clinic in an open building on an empty lot in the middle of Goiânia.

A cesium radiation therapy device consists of a massive metal beam
attached to thick concrete walls from which extends a strong arm that suspends
a device in the form of an elongated sphere (about 700 kg and about 60 cm
diameter) on rotateable gimbals. Inside the device is a large amount of lead
shielding around a steel cylinder, which contains mostly lead, (12 cm high by
30 cm diameter and 120 kg mass) and in the center of the cylinder is a smaller
cylinder (3 cm high by 3.6 cm diameter and 93 g mass) of cesium chloride powder
held together by some non-radioactive material. A channel ("window") filled
with iridium extends from the cesium cylinder to the curved surface of the lead
cylinder; it absorbs less of the cesium's gamma rays than does the lead. The
cylinder can be rotated so that the iridium window is aligned with a channel to
the outside of the steel/lead cylinder when treatment is desired.

At the time of GRI it has been estimated that, because of cesium-137's
thirty-year half-life, there were 19 g of cesium in the source and it emitted
1370 curies. The steel/lead cylinder that encloses the cesium source apparently
can be removed easily from the device and apparently would emit much gamma
radiation through the window.

Brazilian Nuclear Policy; A
Brief History

In the 1950's nuclear energy was seen as a solution to the world's
energy supply problem. Despite cheap petroleum, a non-renewable energy source,
an energy crisis was on the horizon. In nuclear energy man had achieved
fantastic domination over nature in that a few grams of a specific material
could release as much energy as tons of coal. The enthusiasm was great and
pacific movements, such as the Pugwash conferences, were weakened by propaganda
put out by governments interested in developing nuclear energy. Despite the
fright generated by Hiroshima and Nagasaki, the magical and the peaceful side
of this large energy source were strongly involved in the propaganda.

In Brazil the enthusiasm was not different. The first reactor acquired
by Brazil in the 1950's was obtained through the US program "Atoms for Peace"
and was installed at University of São Paulo. The second reactor was
installed at the Federal University of Minas Gerais in Belo Horizonte and the
third at the Federal University of Rio de Janeiro in the 1960's. Despite the
fact that the first three research nuclear reactors are at large universities,
they have very little connection to the academic departments of the
universities.

The national government agency CNEN (Comissão Nacional de Energia
Nuclear) was created in 1956 with the objective to develop nuclear energy in
Brazil and institute strong controls on the export of nuclear materials. (For
example, monozoitic sands had been used as ocean ship return ballast by other
countries.) After the taking of power by the military in 1964, CNEN was largely
controlled by the military. An example of the dictatorial power was when
Brazilian physicists/engineers were discussing which type of reactor was best
for Brazil. Some argued, with a nationalist argument, for a natural uranium
reactor whose fuel could be supplied from within Brazil (this is what Argentina
chose); others argued for enriched uranium reactors, despite the fact that
Brazil had no capability for producing enriched uranium. The military regime
opted, at the end of the 1960's, to buy an enriched uranium 620-MW reactor from
Westinghouse, which was installed at Angra dos Reis in the state of Rio de
Janeiro, and which has never operated properly and still today has many
problems. It was obvious to all concerned that the military wanted enriched
uranium not only for reactors.

In 1975, at the peak of the "oil crisis," the government under General
Ernesto Geisel made an accord with Germany for the construction of eight 1300-MW
reactors by 1990. The accord also provided the possibility of Brazil acquiring
sixty more reactors by the year 2000. A German company KWU, in the Siemens
group, became associated with the Brazilian government company,
Nuclebrás, for fabrication of the reactor components and enrichment and
reprocessing of uranium fuel in Brazil. Only one of these proposed reactors is
presently under construction, although ground has been broken for the second
one - both at Angra dos Reis where the Westinghouse reactor is. A third one is
planned for the state of São Paula.

The Brazilian Society of Physics (Sociedade Brasileira de Física - SBF) protested against the accord from the beginning; it questioned the
dimension of the program, the lack of previous debate, the small estimate of
the hydroelectric power potential of Brazil, the dangers of nuclear energy and
the vulnerability of the process of uranium enrichment by centrifugation. The
reprocessed uranium and plutonium was suspected by SBF to be eventually used
for building nuclear bombs. The Brazilian Society for Advancement of Science
(Sociedade Brasileira para o Progresso da Ciência - SBPC) also protested
against the policies of CNEN.

During the Carter administration the U.S. decided not to allow transfer
of this reprocessing technology to Brazil. The transfer of the technology of
enrichment by centrifugation to Brazil had already begun, but after twelve
years it has not proven to be economically viable. The transfer of this
technology is dominated and controlled by KWU, and today it is certain that the
accord does not favor Brazilian domination which Brazil wants.

The economical hydroelectrical power potential estimated at that time
was 100 GW, but has been revised to be 213 GW at present because of higher
petroleum prices. This estimate perhaps should be increased in the future to
include the possibility of transmission of hydroelectric power over long
distances by superconducting lines from the Amazon. The initial estimate for
investment in nuclear power was US$400 per kW, far under the current real cast
of US$3500 per kW, which is about three times the cost of traditional
hydroelectric power investment.

In the 1980's more people began to discuss the problems of nuclear
energy in Brazil. The erosion of the military dictatorship, the process of
democratization of the society, the lack of success of the Angra reactor, the
Three Mile Island accident and, more recently, the Chernobyl accident set the
tone for the debate. During the time of the last military president (1984) a
massive campaign for direct election of a president peaked, and the political
pressure on the politicians caused them to promise a re-evaluation of the
Brazilian nuclear program. At the beginning of the present civilian government
a commission to evaluate the Brazilian nuclear program was formed. In August,
1986 this commission presented recommendations for several modifications of the
program. Nothing has changed to date.

The central point of the criticism of SBF and SBPC was the fact that
CNEN had the function of implementing the nuclear energy program and, at the
same time, it had the responsibility for regulation of nuclear installations.
CNEN is connected to the President through the Casa Militar, the president's
military policy making body, and therefore has very little initiative to
satisfy public demands. The hole at Serra do Cachimbo (see below), secret CNEN
bank accounts and the nuclear submarine program still today do not have
satisfactory public explanations because of the argument of national
security.

The government ignored the recommendations of SBF and SBPC and the
principal recommendation of the commission, mentioned above, that was recently
formed to evaluate the Brazilian nuclear program; namely, that CNEN should not
perform regulation but that a new commission should be created with the
function of standardization, licensing and inspection of nuclear
facilities.

A Chronology of the Goiânia
Radiation Incident

This is a summary of reports that appeared in several newspapers,
magazines and official documents in Brazil.

A separately operated therapy clinic was built near a large charity
hospital in downtown Goiânia in 1971. A cesium device as described above
was first used, but was supplanted by the more modern cobalt device in 1978. In
December, 1985 the clinic, along with the cobalt device, was moved to another
location in Goiânia, but the cesium device was left in the radiation room
of the old clinic building. Some litigation ensued between the hospital and the
clinic which, it is claimed by the former clinic owner, prevented clinic
personnel from coming back later to remove the cesium device. However, it was
reported that in early 1986 some therapy work was done using the cesium source
in the old building and that the clinic owner removed some parts of the
building in mid-1987. Also, no security guard was posted at the building after
January 15, 1987.

In 1984 the state of Goás purchased the hospital-clinic block and
demolished the hospital building, but left the clinic building because of the
legal problems associated with it. When GRI occurred the clinic building was
completely open with large holes in the walls and was apparently used by the
homeless for sleeping quarters (One month after GRI began the authors freely
walked in and observed human refuse and the massive iron support for the
radiation device lying on the floor of the radiation room.)

On September 13, 1987 two of Goiânia's many scavengers entered the
clinic and removed the lead cylinder from the cesium device and took it to one
of their houses. According to our knowledge of the source, as described above,
it appears that this cylinder would emit a beam of gamma radiation through its
window. For four hot nights they tried to hammer open the cylinder with no
success.

On September 16 they broke through the iridium window using sharp tools
and received high doses of gamma radiation as they observed a beautiful deep
blue light emanating from the opening. (The blue light is caused by absorption
of the gamma rays by chlorine and its reemission of visible light.) Also,
cesium chloride dust could now escape into the environment. The scavengers also
collected old papers; small amounts of cesium chloride were later found in a
bundle of papers in a paper factory in São Paulo, 850 km from
Goiânia. (One of the scavengers had his right arm amputated at the elbow
on October 14 because of the effects of the radiation.)

On September 17 the two scavengers took the lead cylinder to a nearby
junk yard owned by the neighborhood "boss." On September 21 the junk dealer
promised to pay 1600 cruzados (about $25 at that time) for the blue cylinder
inside the steel/lead cylinder; he wanted to make a ring for his wife out of
it. The cylinder was then placed in the clothes closet in his wife's
bedroom.

On September 21 the wife of the junk dealer noticed that several of her
relatives had diarrhea, so she took some soft drink to the local sanitary
office (Vigilância Sanitária de Goiás - USG) to see if it
might be the cause. The answer was negative.

On September 23 the lead cylinder was hammered apart by the junk yard
workers to release the cesium chloride cylinder, probably in several pieces.
(Two of the workers, Israel Batista dos Santos and Admilson Alves de Souza,
died on October 29 in a Rio de Janeiro hospital.)

Also, on September 23 one of the contaminated persons traveled to
Anápolis, 60 km from Goiânia, and some small amounts of cesium
chloride dust were later found in two houses there. (Small patches of cesium
chloride contamination were later found at several scattered locations around
Goiânia where the participants had been. The authors observed several
times the recovery of such contamination in their normal driving around
Goiânia.)

On September 24 a brother of the junk dealer used a screw driver to
gouge out some of the cesium chloride dust and carried it to his nearby home.
He rubbed some of it on the concrete floor where his six- year-old daughter
played. The daughter ate food with her hands which had on them cesium chloride
dust from the floor. A family dog also ingested some of the dust. (On October
23 the daughter, Leide dos Neves Ferreira, died in a hospital in Rio de
Janeiro. She was buried in a lead coffin surrounded by concrete in a
Goiânia cemetery. Her burial was protested by a nearby crowd.)

Also, on September 24 another brother of the junk dealer took a piece of
the cesium chloride by public bus home with him in his pocket and another
brother used some of the cesium chloride dust to make a cross on his abdomen.
Two pigs of one of the brothers ingested some of the cesium chloride dust.
(Later a total of twenty-three chickens and ducks, five pigs, two dogs and two
rabbits were killed because they were contaminated.)

On September 27 two other scavengers of the same group went to the
abandoned clinic and took the outer portion of the cesium radiation device,
which was more than 600 kg.

On September 28 the wife of the junk dealer had one of the workers take
the steel/lead cylinder, minus much of the lead, that had glowing cesium
chloride dust on it to the USG and said that she thought it was killing her
people. (Neighbors thought they had AIDS because their hair was falling out and
they had burns on their skin.) The cesium remained at USG the rest of the day
while the woman was examined at the Center for Information on Toxic Drugs. The
examining physician suspected radiation as the cause, so he called two local
physicists who verified with a scintillation meter that the material at USG was
highly radioactive. Maria Gabriela Ferreira, the wife of the junk dealer,
thereby possibly saved many other lives. (On October 23 Maria died in a
hospital in Rio de Janeiro.)

About 100,000 people were examined for radioactive contamination; of
these 244 were found to be contaminated with cesium chloride. After
decontamination procedures, 49 of these were interned for medical observation;
ten of the most serious cases were interned in a special hospital in Rio de
Janeiro. On November 5 fourteen persons were still being treated for
contamination. It is impossible to determine how many people were highly
radiated without being contaminated with cesium chloride. One estimate was that
a total of 2000 people received high radiation doses. Some effort is being made
to examine all persons who lived within a certain radius of the major sites of
contamination.

It has been estimated that at least six people received a total
radiation dose of 400 to 1000 rems (for gamma rays, rems = rads =100 erg/g of
body material). The body of Leide das Neves Ferreira emitted 25 rads per day
when she died.

At least fourteen different contaminated areas have been located in
Goiânia, most of them at very low levels. An area of 2000 square meters
was vacated of inhabitants, of which 240 square meters were considered to be
contaminated by cesium chloride. The isolated area contains twenty-five small
houses and two junk yards.

The decontamination of the soil and buildings often appeared to be a
comedy of errors. To begin, the technicians arrived in Goiânia without
proper protective clothing, so they purchased white coveralls and tennis shoes
from a local clothing store. Same technicians became contaminated because they
had improper clothing. Some of the monitoring devices became contaminated and
thus recorded their own contamination, rather than the contamination of their
environment. About 350 cubic meters of contaminated material was removed from
Goiânia to a dump site 20 km from Goiânia. (One truck turned over
and spread some contamination over another small area.) The cost of the
radioactive waste removal was estimated at over two million dollars. The
governor of Goiás has stated that the highly contaminated area will be
converted to a park commemorating the victims of GRI and as a reminder of
dangers to the environment.

Luckily, the rainy season was late in arriving, so very little rain fell
to cause spreading of the contamination by run-off.

The three physicians who owned and operated the clinic have been
arrested and charged with criminal neglect. They clam that CNEN had not visited
the clinic during the last five years before GRI. Other information indicates
that it was closer to ten years. A special commission appointed by the
Goiás legislative body concluded that the owners of the clinic and CNEN
were both responsible for GRI occurring. So far no charges have been filed
against any government official.

The Fear of the Populace, The Role of
the Press and Reactions of the Governments

The news that something very dangerous related to nuclear energy had
happened rapidly spread in Goiânia and throughout Brazil. The comparison
with Chernobyl was immediately made. Panic began to envelop the city. The
official information was contradictory, and showed a large lack of technical
knowledge about how to control the situation. The government of the state of
Goiás used all means of communication to avert panic. Because of the
lack of confidence of the citizens in governments, which they believed
consistently did not tell them the truth, rumors were rampant.

Within a few days after the public announcement of GRI an undetermined
number of people moved out of Goiânia; for example, the American Field
Service removed its several United States exchange students. Many people who
had planned to come to Goiânia for various reasons canceled their plans
and concerts were canceled because of fear generated by national and
international news stories about GRI, These reports compared GRI to Chernobyl,
Three Mile Island and other nuclear accidents. After the initial panic the city
became relatively calm, because there were few visible signs of the effects of
GRI, despite the continuing news of a severe problem in Goiânia.

The fear of the populace increased again when knowledge became available
about the radioactive wastes of GRI. For example, a Goiânia dentist asked
one of the authors (LDR) if he was afraid to live in Goiânia. The federal
government quickly decided that the wastes would be deposited in a 300-meter
deep hole at Serra do Cachimbo air force base in the state of Pará in
northeast Brazil. (This hole, according to Sociedade Brasileira de
Física, has similar characteristics to the holes the U.S. uses for
nuclear bomb tests; however, the Brazilian military has always stated that they
are not planning to build nuclear bombs.) When this news appeared a large
religious festival in Belém, the capitol of Pará, quickly became
a massive demonstration against nuclear wastes being deposited in Pará.
The federal government immediately withdrew its decision. After this, every
other state of Brazil indicated that it would not accept the GRI wastes. The
president of the country then stated that the Congress would have to decide
what to do with the wastes, despite the fact that CNEN had, before GRI,
selected several sites around Brazil for long-term storage of nuclear wastes.
So, effectively, the state of Goiás was left to itself to decide what to
do with the nuclear wastes of GRI.

The citizens of Goiás also did not want the wastes stored there,
including the radioactive bodies of the dead. At the first funeral a group of
protesters threw stones at the lead casket. Local motorists blocked the road
for a day to the wastes storage site, twenty kilometers from Goiânia near Abadia,
where about 350 cubic meters of GRI wastes were eventually deposited. The
government of Goiás indicated that this was a temporary site for the
wastes.

Food and clothing products of Goiás were not accepted by people
in other states for several weeks after GRI because of contamination fears. It
was reported that the important clothing and other industries in Goiânia
suffered reduced sales of about 40% during the months of October and November.
It was reported that the governor of another rice producing state urged that
Brazilian's should not buy rice from the state of Goiás because it might
be contaminated. Travelers from Goiânia were occasionally refused rooms
in hotels in other states of Brazil. Government officials tried to use
television to alleviate these fears. The governor of Goiás started
spending his weekends near the wastes deposit site to indicate that there was
no reason to be afraid of contamination.

About one hundred miles from Goiânia is the lovely hot-springs
town of Caldas Novas. Two months after GRI began the occupancy rate at the many
hotels there was reported to be 14% of normal. On a casual drive around the
town one author (LDR) noticed that the usual many large tour buses from Rio de
Janeiro and São Paulo were not there.

Various persons accused the news media of exaggerating the problem and
thereby increasing the panic, We think that the communication problem was not
so much exaggeration by the press, but was largely due to lack of timely,
adequate, organized and accurate information supplied by CNEN to the press.
Instead of one authoritative spokesperson there were many contradictory spokespersons;
thus the press had to decide which one was correct. An example of the poor
communication between the technicians and the public was when a spokesman was
asked when the radiation would disappear and he said "never" because of the
asymptotic nature of radioactive decay. One newspaper then carried the headline
"The contaminated area will not be habitable for over 100 years." The
information was correct but incomplete and was not properly communicated to the
public. A month after GRI began the press began consciously playing the role of
indicating that life in Goiânia had returned to normal, which helped
cause the fear to rapidly diminish. However, the fear of people outside the
state of Goiás remained high for several more months.

Fear of the unknown is a normal evolutionary-useful characteristic of
man. In an age when many dangerous materials are routinely used by a society,
the leaders of the society have a strong obligation to assure that the use of
the materials follows well-tested procedures and that the populace is well
educated about the real dangers of using the materials. Only then will
ill-founded fears be conquered.

The Future for the Victims of
GRI

Most of the victims of GRI are quite poor people. An exception is the
junk dealer and his wife; reports indicated that the wife worked very hard at
making the business a success. Some of the victims who owned things have now
lost all or part of them because of cesium chloride contamination. Irrational
fear of them or anger against them will probably make it difficult for them to
find housing and employment in the future, and their lives may be in danger of
retributive action. (However, the junk dealer has tried to capitalize on his
instant fame; for example, he asked reporters for money for permission to take
his picture and asked for and got a visit from a famous actress.)

A group of professors in Brazil plans to study the victims for several
years, but we know of no long-term dedicated funds that will give such a study
the longevity it requires. There are large needs for more than study: there are
needs for adequate medical care, housing and employment opportunities for the
victims. When the excitement of GRI fades in the future and Brazil's many other
crises supplant it in the public eye, it appears certain to us that, unless
special long-term arrangements are made now, none of these necessities will be
supplied. We suspect that even the proposed study will fade away. In fact, when
this article was completed in February, 1988 GRI appeared to have faded into
the background of Brazil's other problems.

Brazil should now apply for, or some international organization should
take the initiative to offer, dedicated long-term international financial help
to properly care for and study the victims of GRI. Their plight is the result
of international trade in dangerous high technology materials promoted by the
developed countries. The knowledge gained from learning how to properly care
for the victims and from a long-term study of the victims could be of great
benefit to the entire world.

Medical X-Rays in Brazil

From the author's personal experiences of living in Brazil and from
informal discussions with other residents and medical personnel involved with
medical x-rays, we offer the following general conclusions about the use of
medical x-rays in Brazil.

There is very little, if any, regular inspection of medical x-ray
devices in Brazil. Although there are programs to train operators for these
devices, it is probable that, in many cases, the devices are operated by
persons who have had no formal training. There appears to be no federal or
state organized procedure for monitoring the exposure of the operators. We
believe that the taking of unnecessary x-rays of patients is standard practice
in Brazil. As evidence of the last statement, one of the authors (LDR) relates
in the following paragraphs his experiences with medical x-rays in Brazil. (The
first person will be used in the narration.)

To give me a cultural visa for a stay of six months in Brazil, the
Embassy of Brazil in Washington, D.C. required that I be examined by a specific
doctor in Washington, which examination included chest x-rays. (No possibility
was allowed for using any recent chest x-ray.) At the cost of a five-hundred
mile round trip from my home and a $240 doctor bill, I gave my chest x-ray
films to the immigration health official at the Rio de Janeiro airport.

After starting work in Goiânia I was informed that I had to have
another chest x-ray for a "health card." I went to the small "health office" on
Tocantins Avenue where a young man used a quite old machine to take the x-ray.
The next day when I returned to get the x-ray film, I was told that the
operator "overexposed" me and that I would have to take another x-ray. I was
very disturbed by this, but finally relented. This time I was taken to an old
Volkswagen van on the sidewalk which contained an obviously old x-ray machine.
(Later I noticed that there are several of these vans associated with the
office; apparently they drive them around the state taking people's x-rays.)
The next day when a friend went by to pick up the x-ray film he was told that
they had lost my x-ray and that I would have to take another one. My friend
told them in no uncertain terms that I would not take another one, so, after
some searching, they "found" an x-ray film for me.

In a period of one month I had had three chest x-rays, at least one of
which was of doubtful safety. From this isolated experience and discussions
with Brazilian citizens, we believe that Brazilian residents are regularly
being over exposed to x-ray radiation.

Conclusion

The Goiânia Radiation Incident was the most serious event ever
recorded that involved a medical radiation source. At the time of writing this
report four victims have died and many more lives will be drastically
shortened. It is likely that the future for the GRI victims will be very bleak
unless some extraordinary action is taken.

The late arrival of the rainy season and the actions of Maria Gabriela
Ferreira may have saved many other people from being victims.

Brazil should promptly institute a tough licensing and inspection
regimen for medical radiation sources, including x-rays. A new regulating
organization with no ties to the nuclear industry or the military should be
given strong power to regulate nuclear materials in Brazil.

A major effort should be made to locate all nuclear radiation sources in
all countries of the world. The effects of GRI, due to negligent behavior,
should put great fear in the minds of all the world's community leaders of what
chaos could be caused by one of these sources due to purposeful behavior.